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Frequency of ring abscess and cuspal infection in active infective endocarditis involving bioprosthetic valves
1Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
Abstract:
When active infective endocarditis (IE) involves a bioprosthetic valve, the infective process may involve only the cusps or sewing ring or both. We studied 34 patients with infected bioprostheses to determine whether the infection involved the cusps or ring, or both, because these locations could affect prognosis. In the 5 patients in whom active IE began < 60 days after operation, the infection involved the cusps only in 2, the ring only in 2, and both in 1. The 29 patients in whom signs and symptoms of active IE appeared > 60 days after valve replacement were subdivided into 3 categories based on the valve or valves replaced. In the 16 patients with isolated aortic valve replacement, the infection involved the cusps only in 6, the ring only in 4, and both in 6. In the 6 patients with isolated mitral valve replacement, the infection involved the cusps only in 2, the ring only in 1, and both in 3. In the remaining 7 patients, 15 native valves were replaced with bioprostheses, and 10 of them were infected. The infection involved the cusps only in 7, and both the cusps and ring in 3. Of all 34 patients, 13 had operative excision of the infected bioprosthesis: 1 died within 60 days of the bioprosthetic excision, and 1 was lost to follow-up; of the remaining 11 patients, 4 died late (1.5, 3, 5 and 14 years), and the other 7 are alive 5 to 10 years after bioprosthetic excision (all in New York Heart Association functional class I or II). Thus, although infection limited to the bioprosthetic cusps may reasonably allow a better outlook, reoperation with infection involving the annular ring (8 of 13 reoperation patients) does not prevent successful outcome.
Insights
Infective endocarditis affecting bioprosthetic valves can involve cusps or the sewing ring. Infection limited to cusps may offer a better prognosis, but ring involvement does not preclude successful outcomes after reoperation.
Area of Science:
- Cardiovascular Surgery
- Infectious Diseases
- Prosthetic Valve Endocarditis
Background:
- Active infective endocarditis (IE) in bioprosthetic valves presents a complex clinical challenge.
- The anatomical site of infection—cusps, sewing ring, or both—may influence patient prognosis.
- Understanding these distinctions is crucial for effective management of bioprosthetic valve infections.
Purpose of the Study:
- To investigate the specific locations of infection (cusps, sewing ring, or both) in patients with active infective endocarditis involving bioprosthetic valves.
- To determine if the site of infection impacts the prognosis and outcomes following treatment, particularly reoperation.
Main Methods:
- Retrospective study of 34 patients diagnosed with active infective endocarditis on bioprosthetic valves.
- Classification of infection site based on operative findings: cusps only, sewing ring only, or both.
- Analysis of patient outcomes, including mortality and functional status, in relation to infection location and treatment received (e.g., operative excision).
Main Results:
- Early IE (<60 days post-op) showed varied involvement (cusps, ring, or both).
- Late IE (>60 days post-op) in isolated aortic or mitral valve replacements also demonstrated diverse infection sites.
- Of 13 patients undergoing reoperation, 8 had annular ring involvement, yet 7 remained alive and in good functional class (NYHA I/II) 5-10 years post-excision.
Conclusions:
- Infective endocarditis limited to bioprosthetic valve cusps may be associated with a more favorable outlook.
- Involvement of the sewing ring, while potentially more complex, does not necessarily preclude successful outcomes after reoperation.
- The anatomical extent of infection in bioprosthetic valve infective endocarditis is a significant factor in patient prognosis and management strategy.